HomeMy WebLinkAboutMortgage_Sampson 4 STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
a FOR DEDUCTION FROM ASSESSED VALUATIO TT
ctState Form 43709(R12/6-14) y
Prescribed by Department of Local Government Finance 19NLJ.
INSTRUCTIONS: ~ File Mark
To be filed in person or by mail. FF qq q 99�� cc Form fit with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for whic t)Te�deSuttiddll Gought.
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is County Auditor
located on or before January 5 of the immediately succeeding calendar ye. ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file • i I' t or o the county
where the property is located during the twelve(12)months befa '� „1 eduction is sought.
See reverse side for additional instructions and qualifications. 0 II Y AUDITOR
Applicant(owner a'contract buyer-see restrictions on reverse side)
Sampson, Deborah K. .
Taxing District Key number/legal description Record ilumber Page number
Ft. Branch 26-19-19-101-000-747-026/Smith Enlg 13 t4c• 5�if J�
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
March 1,anent year March 1,current year date of application legal or ecirble owner?
131,600 90,811 117,928 Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other than spouse,indicate with whom
If name on record is different than that of applicant,indicate below: Is th roperty in question:Annually Assessed
Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
Ruoff Home Mortgage
Address of mortgagee or contract seller(number and street.city.state.and ZIP code)
972 Emerson Parkway, Suite C, Greenwood, IN 46142
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street.city,state,and ZIP code)
Does applicant own property in a If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
other county , property for
in Indiana? Yes No current year? ❑Yes ❑No
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract indebtedness that is recorded in the county
recorder's office(including any home equity line of credit that is recorded in the county recorder's office)that is the basis for the deduction.
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 20 20 20 20
1 , •
Signature of Count- ditor 1 / County I Date(month,day,year)
I/We certify under the penalty of perjury that the above and fore•otng information is true and correct and that the applicant is a resident of Indiana and
owner I contract buyer of the aforementioned property on date application is filed. .
5'.y L.e(owner's full name) Date(month,day,year)
K . . --jr a� o2a-/ to
AF 1 ly esident address of applicant(number and Feet, state,and ZIP code)
5aR s. .Q,-A. Ar e_ .
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street,city,state,and ZIP code)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000.